Jaundice Overview

Jaundice is a yellow discoloration of the skin, mucous membranes, and the whites of
the eyes caused by increased amounts of bilirubin in the blood. Jaundice is a sign of an
underlying disease process.
Bilirubin is a by-product of the daily natural breakdown and destruction of red blood
cells in the body. The hemoglobin molecule that is released into the blood by this
process is split, with the heme portion undergoing a chemical conversion to bilirubin.
Normally, the liver metabolizes and excretes the bilirubin in the form ofbile. However, if
there is a disruption in this normal metabolism and/or production of bilirubin, jaundice
may result.

Jaundice Causes
Jaundice may be caused by several different disease processes. t is helpful to
understand the different causes of jaundice by identifying the problems that disrupt the
normal bilirubin metabolism and/or excretion.

Pre-hepatic (before biIe is made in the Iiver)
Jaundice in these cases is caused by rapid increase in the breakdown and destruction
of the red blood cells (hemolysis), overwhelming the liver's ability to adequately remove
the increased levels of bilirubin from the blood.
Examples of conditions with increased breakdown of red blood cells include:
O malaria,
O sickle cell crisis,
O spherocytosis,
O thalassemia,
O glucose-6-phosphate dehydrogenase deficiency (G6PD),
O drugs or other toxins, and
O autoimmune disorders.

epatic (the probIem arises within the Iiver)
Jaundice in these cases is caused by the liver's inability to properly metabolize and
excrete bilirubin. Examples include:
O hepatitis (commonly viral or alcohol related),
O cirrhosis,
O drugs or other toxins,
O Crigler-Najjar syndrome,
O Gilbert's syndrome, and
O cancer.

Post-hepatic (after biIe has been made in the Iiver)
Jaundice in these cases, also termed obstructive jaundice, is caused by conditions
which interrupt the normal drainage of conjugated bilirubin in the form of bile from the
liver into the intestines.
Causes of obstructive jaundice include:
O gallstones in the bile ducts,
O cancer (pancreatic and gallbladder/bile duct carcinoma),
O strictures of the bile ducts,
O cholangitis,
O congenital malformations,
O pancreatitis,
O parasites,
O pregnancy, and
O newborn jaundice.

Jaundice in newborn babies can be caused by several different conditions, although it is
often a normal physiological consequence of the newborn's immature liver. Even though
it is usually harmless under these circumstances, newborns with excessively elevated
levels of bilirubin from other medical conditions (pathologicjaundice) may suffer
devastating brain damage (kernicterus) if the underlying problem is not addressed.
Newborn jaundice is the most common condition requiring medical evaluation in
newborns.

The following are some common causes of newborn jaundice:

PhysioIogicaI jaundice
This form of jaundice is usually evident on the second or third day of life. t is the most
common cause of newborn jaundice and is usually a transient and harmless condition.
Jaundice is caused by the inability of the newborn's immature liver to process bilirubin
from the accelerated breakdown of red blood cells that occurs at this age. As the
newborn's liver matures, the jaundice eventually disappears.

MaternaI-fetaI bIood group incompatibiIity (Rh, ABO)
This form of jaundice occurs when there is incompatibility between the blood types of
the mother and the fetus. This leads to increased bilirubin levels from the breakdown of
the fetus' red blood cells (hemolysis).

Breast miIk jaundice
This form of jaundice occurs in breastfed newborns and usually appears at the end of
the first week of life. Certain chemicals in breast milk are thought to be responsible. t is
usually a harmless condition that resolves spontaneously. Mothers typically do not have
to discontinue breastfeeding.

Breastfeeding jaundice
This form of jaundice occurs when the breastfed newborn does not receive adequate
breast milk intake. This may occur because of delayed or insufficient milk production by
the mother or because of poor feeding by the newborn. This inadequate intake results
in dehydration and fewer bowel movements for the newborn, with subsequent
decreased bilirubin excretion from the body.

CephaIohematoma (a coIIection of bIood under the scaIp)
Sometimes during the birthing process, the newborn may sustain a bruise or injury to
the head, resulting in a blood collection/blood clot under the scalp. As this blood is
naturally broken down, sudden elevated levels of bilirubin may overwhelm the
processing capability of the newborn's immature liver, resulting in jaundice.

Jaundice Symptoms
Jaundice is a sign of an underlying disease process. .
Common signs and symptoms seen in individuals with jaundice include:
O yellow discoloration of the skin, mucous membranes, and the whites of the eyes,
O light-colored stools,
O dark-colored urine, and
O itching of the skin.
The underlying disease process may result in additional signs and symptoms. These
may include:
O nausea and vomiting,
O abdominal pain,
O fever,
O weakness,
O loss of appetite,
O headache,
O confusion,
O swelling of the legs and abdomen, and
O newborn jaundice.
n newborns, as the bilirubin level rises, jaundice will typically progress from the head to
the trunk, and then to the hands and feet. Additional signs and symptoms that may be
seen in the newborn include:
O poor feeding,
O lethargy,
O changes in muscle tone,
O high-pitched crying, and
O seizures.

hen to Seek MedicaI Care
Call a health care practitioner if you or your baby develops jaundice. Jaundice may be a
sign of a serious underlying medical condition.
f you are unable to reach and be seen by your health care practitioner in a timely
manner, go to the emergency department for further evaluation.

Exams and Tests
The health care pracitioner will need to take a detailed history of the patient's illness,
and he or she will also be examined to see if there are any findings that indicate the
cause of the patient's jaundice. However, additional testing is usually required to clearly
determine the underlying cause of jaundice. The following tests and imaging studies
may be obtained:

BIood tests
These may initially include a complete blood count (CBC), liver function tests (including
a bilirubin level), lipase/amylase level to detect inflammation of the pancreas
(pancreatitis), and an electrolytes panel. n women, a pregnancy test may be obtained.
Additional blood tests may be required depending upon the initial results and the history
provided to the practitioner.

&rinaIysis: Urinalysis is an analysis of the urine and is a very useful test in the
diagnosis of screening many diseases.

Imaging Studies
O &Itrasound: This is a safe, painless imaging study that uses sound waves to
examine the liver, gallbladder, and pancreas. t is very useful for detecting gallstones
and dilated bile ducts. t can also detect abnormalities of the liver and the pancreas.
O Computerized tomography (CT) scan: A CT scan is imaging study similar to an X-
ray that provides more details of all the abdominal organs. Though not as good as
ultrasound at detecting gallstones, it can identify various other abnormalities of the
liver, pancreas, and other abdominal organs as well.
O ChoIescintigraphy (IDA scan): A HDA scan is an imaging study that uses a
radioactive substance to evaluate the gallbladder and the bile ducts.
O Magnetic resonance imaging (MRI): MR is an imaging study that uses a magnetic
field to examine the organs of the abdomen. t can be useful for detailed imaging of
the bile ducts.
O Endoscopic retrograde choIangiopancreatography (ERCP): ERCP is a procedure
that involves the introduction of an endoscope (a tube with a camera at the end)
through the mouth and into the small intestine. A dye is then injected into the bile
ducts while X-rays are taken. t can be useful for identifying stones, tumors, or
narrowing of the bile ducts.

Liver Biopsy
O n this procedure, a needle is inserted into the liver after a local anesthetic has been
administered. Often ultrasound will be used to guide placement of the needle. The
small sample of liver tissue which is obtained is sent to a laboratory for examination
by a pathologist (a physician who specializes in diagnosis of tissue samples). Among
other things, a liver biopsy can be useful for diagnosing inflammation of the liver,
cirrhosis, and cancer.

Jaundice Treatment
Treatment depends on the cause of the underlying condition leading to jaundice and
any potential complications related to it. Once a diagnosis is made, treatment can then
be directed to address that particular condition, and it may or may not require
hospitalization.
O Treatment may consist of expectant management (watchful waiting) at home with
rest.
O Medical treatment with intravenous fluids, medications, antibiotics, or blood
transfusions may be required.
O f a drug/toxin is the cause, these must be discontinued.
O n certain cases of newborn jaundice, exposing the baby to special colored lights
(phototherapy) or exchange blood transfusions may be required to decrease elevated
bilirubin levels.
O Surgical treatment may be required.

SeIf-Care at ome
The objectives of home therapy include symptom relief and managing the medical
condition causing the underlying jaundice. The various measures that may be
undertaken include:
O Maintain adequate hydration by drinking fluids, and rest as needed.
O Take medications only as instructed and prescribed by a health care practitioner.
O Avoid medications, herbs, or supplements which may cause detrimental side effects.
Consult a health care practitioner for advice.
O Avoid drinking alcohol until the patient has discussed it with their health care
practitioner.
O Certain dietary restrictions may be recommended by a health care practitioner.
O n certain cases of newborn jaundice, the parents or caregivers can place the baby
next to a well lit window a few times a day to decrease elevated bilirubin levels. n
more severe cases, a health care practitioner may need to discharge the baby home
from the hospital with home phototherapy.
O Provide adequate milk intake for the baby in cases of breastfeeding jaundice.
O f symptoms worsen or if any new symptoms arise, consult a health care practitioner.

MedicaI Treatment
Treatment varies based on the medical condition responsible for causing jaundice, and
the associated symptoms and complications. Treatments may include the following:
O supportive care,
O V fluids in cases of dehydration,
O medications for nausea/vomiting and pain,
O antibiotics,
O antiviral medications,
O blood transfusions,
O steroids,
O chemotherapy/radiation therapy, and
O phototherapy (newborns).

Prevention
The underlying medical condition causing jaundice can in some cases be prevented.
Some preventive measures include the following:
O Avoid heavy alcohol use (alcoholic hepatitis, cirrhosis, and pancreatitis).
O Vaccines for hepatitis (hepatitis A, hepatitis B)
O Take medications which prevent malaria before travelling to high-risk regions.
O Avoid high-risk behaviors such as intravenous drug use or unprotected intercourse
(hepatitis B).
O Avoid potentially contaminated food/water and maintain good hygiene (hepatitis A).
O Avoid medications that can cause hemolysis in susceptible individuals (such as those
with G6PD deficiency, a condition that leads to red blood cell breakdown after
consumption of certain substances).
O Avoid medications and toxins which can cause hemolysis or directly damage the
liver.

ww.emedicinehealth.com/jaundice